Writing with Scissors is the blog site of Howard Rodenberg, MD MPH, former Kansas State Health Director and columnist for the Journal of Emergency Medical Services (JEMS). He is a father, emergency physician, and slightly-past-fifty curmudgeon with great hair for his age. The "scissors" in question refer to those used by editors to weed out all things opinonated, controversial, or politically inappropriate...translated as "anything funny."

Sunday, January 10, 2010

We all learned in grade school about homonyms They’re the words that sound the same with but have different spellings (like “bear” and “bare”), or that are spelled the same with different meanings (“bear,” as to carry, or “bear,” as to Yogi). But I’m always surprised at how useful certain homonyms can be.

Billy Ray was brought into the ED by EMS after riding his bicycle into a moving car. That much we knew from the paramedics. To ask Billy Ray, however, it turned out that he had a (present participle describing an Oedipal relationship) fall at some undefined (term alluding to said Oedipal relationships) place and that the (continuing maternal carnal experience) paramedics delivered him against his will to this (persistent use of similar euphemism) place. Professional that I am, I continued with my exam, braving the torrent of commentary ranging from other relationships I might have with members of my own gender to comments regarding bodily excretions as well as thoughts regarding the legitimacy of my parentage.

(For those of us who grew up on Schoolhouse Rock, you could make the case that Billy Ray’s use of the aforementioned term does not really represent a homonym, but has simply unpacked a single a multipurpose adjective meaning “generally unpleasant.” I prefer the homonym explanation, as one senses that he says it with different intent, and additional virulence, at some moments than others. But I digress.)

I told Billy Ray that he needed to stay in the exam area, keep on his neck collar, and we’d get X-rays of the things that hurt. I also asked him to simmer down so as not to be a distraction to other patients in the ED. His reply demonstrated his unique insight into the process of medical decision-making.

“So if got a (reference to a disagreeable situation) bump on my (impolite descriptor originating in World War II), you’d get a (expression of displeasure) X-ray of that?”

“Yep, we probably would.”

“Ahhh, you’re all a bunch of (group of individuals participating in aforementioned relations). Pointing at us individually in turn, he shouted “You’re a (rhyme with other ducker ). And you’re a (repeated phrase). And you, Doctor (sound-alike for jelly maven Mother Smucker), what’s your (adjective form of the nominative term) name again?

I had earlier introduced my self by my real name, but I figured that part of my job was to try to establish a true rapport with my transient acquaintance. One thing I had learned over the years is that with an acutely agitated patient, you don’t get control of the situation by re-orienting them to reality, but by going along with them as an ally. Social scientists would say that it was incumbent upon me to enter his world and build a bond of trust by which we could positively impact his health. So my response was, if not within the bounds of good taste, at least eminently logical.

“That’s one thing you got right. My name is Dr. (sound consonant with brother plucker), and if you don’t get your (previously mentioned incestuous adjective) (euphemism for donkey) back on the bed I’ll have (repeated prior adjective) Security tie you down. Got it?”

His eye widened, and then his face broke into a smile. “Okay,” he said, and sat down on the bed. And once again there was peace in the valley.

(The nurse caring for the patient shared a similar story later in the day. Once she had been called a “Cracker Whore” by a patient, and her reply was, “I’m from Maine. You can call me an Oyster Whore, or a Down-Easter Whore, but I’m not a Cracker.” My favorite one-liner was from several years ago, when another intoxicated member of society addressed a nurse as a (person who has foul carnal relations) and she retorted, “I may be a (repeated description), but I’m sure as hell not (performing an act) you.)

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Speaking of ED names, I’ve been called a lot of things over the years. (Some f them are even repeatable in mixed company). My first ED name was “Doogie,” because I become an attending physician about the same time that the “DoogieHowser, MD” show came on the air, and there was some vague resemblance between the youngish me and the even younger Neil Patrick Harris. That moniker lasted about six years, throughout my entire tenure at the University of Florida. There are still people at that institution, and throughout the prehospital care community in Florida, who have no idea that I have an actual name.

Following my Doogie phase there were two other names that were more or less interchangeable. Both depended on the fact that I was tall and skinny with essentially a bowel haircut. Which one applied depended on if I had shaved that morning. If I had, it was “Gilligan.” If not, it was “Shaggy.” (To this day, I often say “Zoinks!” for no apparent reason.

More recently, I have become the “RODHO.” The RODHO (pronounced “Road-hoe”) comes from our computer system here at the hospital where I work, which codes physician names as the first three letters of your last name followed by the first two letters of your first name. If your name is Jawed Panja (one of the hospitalists who works in our facility), the computer thinks you name is, appropriately enough, PANJA. If you’re me, you become the RODHO. If you’re one of my ED colleagues, Dr. Matthew Kocisko, you become the KOCMA, which is even funnier.We’ve had a lot of fun with the RODHO. The RODHO has an Official Motto (“I serve all who solicit my services at discount prices.”) The RODHO is easily adaptable to poetry and music. For example, with apologies to Lewis Carroll:

The time has come, the RODHO said,To speak of many things.Of pain and fractured fibulaeWhich law enforcement brings

Or maybe a Beatles reference:

You have the back pain.You want the Lortab.I am the RODHO!Goo goo gaju.

Or, if you just want to rock out to The Kinks:

RO-AD HO!RO-RO-RO-RO-ROAD HO!RO-RO-RO-RO-ROAAAADD HO!”

(Okay, maybe that last one is better sung. With beer. Lots of beer.)

About two months ago, I got another nickname. I was walking out of the ED about midnight as an ambulance was unloading a patient out the back. The patient saw me, we locked eyes for the briefest moment, and I waved politely. He suddenly reared up on the stretcher and yelled “HEY!”

“Yeah, what’s up?” I’m a friendly guy.

“You look like somebody on TV!”

I’d heard this one before. “Gilligan, right? Shaggy from Scooby-doo?”

“No, man. You look like McDreamy!”

So now I’m also McDreamy. My colleague Keven MacMahon, never one to be left out, has become McSteamy. Three days ago McDreamy and McSteamy were talking to Dr. J.D. Henson, who mentioned that he felt left out without a nickname as well. After momentary consideration, we thought he kind of looked like someone we had all grown up with on PBS, older mustached gentleman with a kind way about him as he made his perpetual postal rounds.

Thursday, January 7, 2010

There are certain scenarios in life that you know are disasters waiting to happen. A date with a woman who has “love” and “hate” tattooed on her knuckles is one of them. So is a voice mail saying, “Hey, it’s Tiger. Whatever happens, you don’t know me.” Likewise, an atheist’s first view of heaven can’t be good.

Medicine has more than a few of these. One of them is the use of the drug warfarin (“Coumadin”). Coumadin is an anticoagulant drug that acts to “thin” the blood. Thinning the blood helps to get oxygen-carrying red blood cells through narrowed vessels and prevents blood clots. It’s an older drug, but still very useful in caring for patients who have suffered strokes, certain heartbeat irregularities (atrial fibrillation), or blood clots in the legs or lungs. More preventative than curative, it stops formation of blood clots that can be life-threatening within the heart, brain, and other sites. It works by inhibiting the Vitamin-K dependent clotting factors within the extrinsic coagulation pathway (Factors II, VII, IX, and X, for those who are keeping score). This is as opposed to another blood thinner called heparin, which acts within the intrinsic clotting pathway by preventing the conversion of prothrombin (Factor II) to thrombin (Factor IIa) through activation of antithrombin. The antithrombin not only blocks the conversion process by inhibiting the action of co-enzyme Factor Xa, but also by diretly inhibiting the action of thrombin itself on fibrinogen (Factor I) to fibrin (Factor Ia).

(No, its really not that interesting, is it? Amazing, complex, a masterpiece of evolutionary handiwork, but still boring. And before you give me too much credit, what I’ve written is all I remember of something that took me weeks to memorize in medical school. This is for two main reasons. The first is that permanent memories are established in the brain by repetition of specific neural pathways, and not once in 23 years since graduation has anyone come up to me and said, “Doc, it’s my extrinsic pathway…it hurts me so.” This is also the mechanism behind the extinction of any knowledge of the Krebs cycle, what fibrin actually is, and how to do a gram stain. On the other hand, I do still know that Trichimonas organisms look like Groucho Marx with a tail, so maybe those years weren’t a total loss.

The second is that, when faced with a choice of occupying my limited brain space with knowing where to find emergency flowers at 3 AM when you’ve really screwed up or remembering the coagulation pathways, I went with that which was most relevant and useful to my life. This is also why I know the names, stadiums, colors, division assignments, owners, head coaches, current won-lost records, playoff formulas, and cheerleader attire of all 32 teams in the National Football League at any given moment but can’t recall how many chambers the heart has. I think it’s between two and six.)

Coumadin is a great drug that, dosed and monitored correctly, does great things. And as long as nothing happens to you, life is good. When something does, however, Coumadin is a disaster waiting to happen.

Take Rocky Royster. Rocky is a mid-forties guy who was working in his kitchen. Basically healthy, he had some bad varicose veins which had developed some blood clots in the past. He was on Coumadin to prevent them from coming back. That December afternoon he was going about, minding his own business, when he slipped on a wet spot on the floor and cut his right leg on a sharp-edged piece of tile sticking up from the floor.

For most of us, what happens next is that we put some pressure on the wound with a kitchen or bath towel, the blood coagulates in the wound, and we drop into the ED an hour or so later to get the wound sewn up. (This, of course, is assuming that the injured party doesn’t pass out at the sight of their own blood. Lucky for me, I’ll pass out even before I see blood from the very idea of pain. This is why I have no fear of addiction to pain pills, as people who are unconscious do a poor job of swallowing tablets.)

But when there’s Coumadin on board, the bleeding doesn’t stop. Ever. Even though Rocky had been a Boy Scout and remembered how to tie a tourniquet around his leg, the paramedics guessed he had at least two liters of blood on the floor. Given that you’ve only got about five liters to start with, this is a major problem, especially when the bleeding shows no inclination to quit.

(While I applaud both the Boy Scouts and Rocky’s actions, paradoxically the tourniquet did not really help him. If the tourniquet is tight enough to occlude flow through the arteries, you can stop bleeding from a site beyond the tourniquet. But if it’s not, blood flow will continue to go down the leg past the tourniquet, but the band around the arm or leg will put pressure on the more superficial and less rigid veins, collapsing them and preventing the return of blood towards the central circulation. This results in more venous congestion in the affected limb and, if there’s an injury to a blood vessel, more bleeding that might otherwise occur.)

He arrived in the ED pale, cold, and clammy, drenched in sweat and semi-conscious. In one of those few moments when life imitates television (“Trauma: Life in the ER”), we dispensed with our usual chit chat and got to work. Respiratory therapy got oxygen on board. One nurse took vital signs; another hooked him up to a monitor; two more worked on finding more IV sites for the inevitable fluids and blood that would follow. My first job was to conduct a quick exam known as the “primary survey” and address any immediate threats to life.

Trauma courses treat us to evaluate patients using the ABC’s. In this case, A stands for airway. If someone doesn’t have an open airway, they can’t breathe, and no oxygen gets into the body. If that occurs, the game is lost. So airway management is the first priority. The B is for breathing, making sure the patient is getting oxygen into the lungs. Like airway problems, if there’s no oxygen getting into the lungs and out to the body death is imminent. C stands for circulation, to insure that the heart is pumping and that blood volume is sufficient to get oxygen from the lungs to the body tissues. We’re taught that when you find a problem, you stop, fix it, and only then move on to the next phase of care.

(The ABC system is, in many ways, backwards to the way most of medicine thinks. Normally when you see a patient, you would complete a full history and physical exam, order some diagnostic tests, and then initiate specific treatment. In this case, you treat the problem first and later figure out what caused it. Over time, you learn that the real benefit of the ABC system is that it’s not limited to trauma care, but that it applies to any patient in the ED no matter what the problem. You can do the ABC exam in 5 seconds. If you ask the patient a question, and they can verbalize a reasonable answer at a reasonable volume, you know that the airway is okay because air gets in and out of the lungs past the vocal cords; that breathing is good because they are able to move enough air to talk; and that circulation is okay because they’re pushing enough blood up to the brain to formulate and answer. That doesn’t mean that someone’s not ill or injured, but it buys you some time to do a more detailed history and exam. It can also be applied to the assessment of blind dates, but that’s another story.)

Rocky’s airway was open, and he was breathing. His oxygen levels, for the moment at least, looked good. He had no blood pressure to speak of, so in addressing his circulatory status it was our task to find the source of blood loss. It wasn’t hard, especially when there’s three pounds of bloody gauze and a hardend layer of duct tape over the leg.

While everyone else was hard at task, I enlisted a tech to help me remove the dressing. First we cut off the tape with those heavy medical scissors that actually will cut of a finger if you’re not looking. (I’ve seen it done.) You never want to rip a dressing form over a wound. If you do, you might also tear off any blood clot that might have formed, making the bleeding worse. The other reason is so that you can gradually peel away the dressing from the wound, looking for specific bleeding vessels as you go.

In Rocky’ case, there was no clot to beware of as the bleeding had never stopped. (That’s Coumadin for you.) The wound was a bloody mess, a seething pool of dark red sticky blood with no visible point where we could get control of it. But at that moment he twitched his leg just a bit, and suddenly we saw a spurt of blood come from the lower edge of the wound. Blocking the flow by compressing the skin just below it, we were able to get to bleeding to wane, and I was able to see the beveled edge of a severed vein. Letting up on the pressure just a bit, we saw the blood flow resume, saturating the towels we had placed beneath his leg; pressure again, and once more we were able to see the gaping inside walls of the vessel.

Now things became mechanical. Once you find the source of bleeding, you can usually tie it off. Taking a clamp holding a threaded needle, I looped the suture through the soft tissues around and behind the vein and brought it back around to the front. Using my own awkward version of a surgical knot, I cinched it down five times. (I’ve always placed five knots on top of one another when I do sutures. No idea why.) I placed a second suture a bit farther along the vein for good measure, and when we released the pressure the offending vessel stayed closed.

When a patient comes in bleeding, there are really two parts to their care. Part One is to stop the bleeding. (While it is a surgical truism that all bleeding stops…eventually...in general it’s good form to stop it before it ceases on its own because there’s no blood left to ooze.) Part Two is to replace what’s lost. In patients with major bleeding, looking at an initial blood count really tells you nothing about real blood loss. The body will contract the smaller blood vessels in the periphery of the body in response to major bleeding, pushing more blood centrally. As a result, an initial blood sample may have an artificially inflated value for the amount of red blood cells present. So what you look for are clinical indicators of blood loss suggesting that the body is trying to compensate. Signs that the body is shifting blood away from the body surface and into the central circulation include cool, clammy skin, profuse sweating, and a pale appearance. The body also needs to circulate the remaining blood faster to the body tissues in order to meet demands for oxygen and waste removal, so both pulse and respiratory rates rise. Blood pressure finally falls when the body’s compensatory means are exhausted.

So with Rocky still looking like a soggy ghost, and no pressure that we could find, we sent for blood. Two units of the red stuff later, Rocky was looking good. Our physician assistant closed up his laceration, he had found to his delight that morphine is a wonderful thing, and he was peering through his glasses at the form he needed to sign so we had permission to treat him. (Mea culpa…we put patient care before the paperwork. Go figure.) His pressure was great, his skin was pink and warm. He leaned forward, hand outstretched. “Thanks, Doc,” he said, grasping me warmly. “You saved my life.” I remembered that the first time I had taken his hand in mine it was cool clammy, the grip of hypoxia, the feel of death. “No problem,” I replied. “It was our pleasure.” Which was, after all was said and done, probably the only thing I could say.

But the real feelings I had were not ones of comfort, teamwork, or accomplishment. In an environment where everything by definition is necessarily wrong, nothing ever really gets fixed, and even incremental success is the exception to the general rule, many of us felt more of an incredulous, “How did that happen?” And in reflection, even as we admittedly did truly save a life, it still feels odd. I didn’t do anything more than put medical duct tape on a garden hose. The stitch I used took ten minutes to learn two decades ago, and it’s still the only kind of technique I know because my hands can’t do the creative surgical knots. Boy Scouts with merit badges in Pioneering can do better than that. My medical degree didn’t make me any smarter, more aware, or more skilled than anyone else in the room. Maybe my discomfort is because all I did was happen to be in the right place at the right time, and I feel bad taking credit for that scheduling accident. Maybe it’s more ego, as we all know that patients who are in extremis usually never recall who saved their life, and always give credit to the first doctor they see after they’re stable. Or maybe it’s because I wish that luck would hold at lottery time so I could leave The Emergent Life and never be troubled with these feelings again.

Tuesday, January 5, 2010

One of the skills you learn very early in The Emergent Life is to separate work from home. Some of us do a better job at compartmentalizing than others, and even those of us who think we do well at it have times where our home life invades our workspace and vice versa. But one place where they don’t meet is in holiday gift-giving. For while I got exactly what I wanted for the holidays at home, the Merry Old Elf never even had a chance to drop down the ventilation shaft at the hospital.

So, if you’re starting to look for gifts for me for next year (and you should be), here’s my official ED Holiday Gift List:

I want to be honest with patients. I want to be able to tell them the objective facts of their condition and the consequences they face. I want to tell obese patients that when they have back pain, heart disease, or diabetes, that it will never get better unless they lose the weight. I want to tell smokers that they will never get better unless they quit smoking. I want to be able to tell a drug addict that they will never get better unless they stop using drugs. I want to be able to tell patients that their problem is, in fact, not an emergency, and that this is an inappropriate use of the ED. I want to be able to say to patients, “You smoke cigarettes. You drink alcohol. You have an iPod. Don’t tell me you can’t afford your generic $4.00 medication.” I want to tell them that I will not prescribe pain pills, antidepressants, and other medications to treat the complications of their lifestyles, but will be happy to pass out discount coupons for Weight Watchers, Jenny Craig, and local workout clubs. I will pass out flyers with phone numbers Alcoholics Anonymous, Narcotics Anonymous, Al-Anon, Ala-Teen, domestic violence shelters, the Florida Tobacco Quitline, and every psychiatric and rehab facility within a hundred miles. I want to say these things because if patients hear them, they might act on them, and that will do more to improve health and lower costs than any administrative fix ever could. I do not want to have to apologize to patients, administrators, or attorneys for making people feel bad about themselves when the facts speak for themselves. There should be no repercussions from saying these things, because they are not subjective, but based in fact.

I want a big sign out front of the ED that says: “There is no such thing as a free lunch. Or a Pepsi and a meal tray. Or a bus pass, taxi voucher, or hotel room.”

I want to be able to say to those with lifestyle issues that cause illness or injury that we have enough primary care physicians, educational programs, and residential treatment facilities to help all those in need. I also want to say to those who continually refuse to change their ways, and who are receiving care on the taxpayer dollar, that it is no longer our responsibility to rescue you from your own behavior.

I want another big sign that says “A Lack of Planning on Your Part Does Not Make It an Emergency on Mine.”

I want to know what really goes on inside the mind of the non-verbal child with cerebral palsy or the patient with dementia. I want to feel what it’s like so I can try to reach the person inside, whoever or whatever that may be.

I want to be able to express frustration, sarcasm, and anger when the situation requires it. I’m a physician, supposedly sensitive to the human condition, including my own. Dammit, Jim, I’m a doctor, not a robot.

I want someone to take a leap of faith and put into place ED triage protocols that screens out the majority of non-emergent patients. Nobody does because of fear of liability. But given that ED care is inherently expensive, and the vast majority of minor problems are self-limited anyway, it would undoubtedly help to lower health care costs and be fully consistent with health care reform. It would not be consistent whatsoever with trial lawyers vision of a no-risk society, but it’s what we need to do if we’re serious about change.

I want someone to understand that sometimes, stuff just happens.

I want more days where I can’t find a babysitter and I have to bring my son to work, because there is nothing better than leaving the chaos for a few minutes each hour to check on him in the Doctor’s Lounge, ruffle his hair, and remind myself why I show up for this madness each day. I want this without the guilt that comes from using a television, a laptop computer, and a freezer full of ice cream as child care providers the other 55 minutes of every hour.

I want real plastic bowls and plates to eat from in the Staff Lounge. It’s hard to eat from an unused emesis basin without making inevitable connections between soups, chili, or Chinese food and the more usual contents of these catch-alls.

I want to add excitement to work by not only betting on patient’s alcohol levels, but on the results of drug screens and pregnancy tests, the times needed for any given physician to call us back, the number of profanities used in a 60-second period by a patient with an allergy to Law Enforcement, and the odds that a patient on more than one narcotic is seen by a specific, well-known physician in the area. I want a full-time bookie in the ED (paid on commission, so as not to engender any cost to the hospital) to facilitate this effort and to bolster the local economy.

I want to be able to scream out at the top of lungs “FIBROMYALGIA IS DEPRESSION!”

I want a vending machine in the waiting room. The vending machine would be stocked with Tylenol and Motrin (adult and children’s doses), non-narcotic pain relievers and muscle relaxants, a selection of decongestants and antibiotics, and two-day work excuses. The machine would take cash, credit, and the majority of insurance cards with a magnetic stripe on the back.

I want an invisible disruption field in the ED that automatically neutralizes patient cell phones. Nothing bugs me more in the busiest times that waiting for a cell phone conversation to finish before I can do my job. And if you’re not too sick to be chatting away, you’re not sick enough to be in the ED.

I want there to be health care reform that will actually get patients to primary care and follow-up, not give them the illusion of access. Today only 20% of physicians in America will voluntarily see Medicaid patients. The reasons for this are many…low reimbursement, being the main one…and there is no reason to assume their enthusiasm to do so will rise simply because there are going to be more patients out there who are covered by the program. Getting coverage to people is essentially a fiscal argument, and despite a polarized political environment it’s actually pretty easy to solve once there’s agreement on the need. Actually getting patients in to see a physician seems to me to be the real, and so far ignored, challenge of health care.

I want an internet connection that’s not blocked at work. Otherwise, how are we supposed to look up things of clinical importance that patients use, like “Horny Goat Weed?” Plus it’s a morale booster. Being able to watch YouTube and re-enact the moves of The Pips in plastic rolling chairs at the nursing desk while shouting “WOO WOO” at the appropriate times is priceless.

I want to emulate my younger and more compact friend Dr. Brent Sieger, and be able to spin a 9” by 12” plastic chart like a basketball on my finger. (I always know when I’ve worked a shift immediately after Dr. Sieger, as I have to crank up the patient beds about a foot and a half to do any procedures or exams.)

I want them to re-establish the Drunk Tank back at the County Jail. If you wake up warm, swaddled, and fed in the ED, your hangover mitigated by fluids and vitamins, what kind of moral lesson is that?

I want to be able to publically acknowledge the benefit of instructional punitive therapy.

I want to actually get paid full price for what I do.

I want patients who say they have fevers to actually have them, for patients who have pain to have some reason for it. I want the time to care about patients who need care, to care for people who use the ED because they need to, not because they want to. I want one day a week to be filled to the brim with patients with real emergencies. I want a weekly reminder of why I really went into this business.

(I asked a trusted colleague of many years, Dr. Raul Lopez, who specifically wanted to see his name in print, what he would add to his holiday wish list. He said, “Not to be on.” Amen to that.)